(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Children's Library | Biodiversity Heritage Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "United States Navy Medical News Letter Vol. 34 No. 5, 4 September 1959"

NavMed 369 




:•: .•:•:•;•:•:■:•.•:•:•:■:•:•:■:■::■:•::■:•:•:■: ::•:■;■:•:•:■:•:•:■:•:■:■• :■:•••:-:•*•:+:•:■: :■:•:•:•:•:•::■: : ::•:•:■:•: •.-..■.■ -.-. ;•:•*:•:•:•:•:•:•:•:•:•:■:■:■* :■: ■•: ■ :•:•-•:•*:•:•: :-'•••:•;-*•:•■■ 

y.y" :.v-.y.yy y.y.y/.y.yy.y.y.y.y.%y.-.y.;.y.y..w^ 

UNITED STATES NAVY ) 




•- , """" v '" 



Rear Admiral Bartholomew W. Hogan MC USN - Surgeon General 
Captain Donald R. Childs MC USN - Editor 



Vol. 34 



Friday, 4 September 1959 



No. 5 



TABLE OF CONTENTS 

Historical Fund of the Navy Medical Department 2 

ABSTRACTS 

Systemic Causes of Abdominal Pain (Part I) 3 

Tobacco Consumption and Mortality 6 

Clinical Characteristics of Leptospirosis 7 

Gushing 1 s Syndrome 10 

Prophylaxis of Streptococcal Infections 12 

Psoriatic Arthritis 13 

Amenorrhea — Sign of Chronic Liver Disease 15 

Significance of Early Treatment of Breast Cancer ]6 

The Effect of Vaccine on Cancer Patients 17 

Role of Salt and Renal Mass in Experimental Hypertension 18 

MISCELLANEOUS 

Association of Military Surgeons Annual Convention 21 

American Board Examination {Obst, & Gynec. , Part I) 22 

Applications for Training in Civilian Institutions , 23 

From the Note Book 23 

DENTAL SECTION 

Corn Yields Tooth Clue 27 

Dental Care— Fiscal Year 1959 28 

Revised Prosthetic Handbook for Technicians 28 

RESERVE SECTION 

Retention Beyond Age 60 Limited by Ruling 28 

How to Accelerate AcDuTra Pay 29 

OCCUPATIONAL MEDICINE 

Tetra-Ethyl Lead Poisoning 30 

EDTA Therapy in Excessive Lead Absorption 32 

Occupational Analysis of Coronary Disease Mortality 35 

Occupational Health and the Local Health Officer 37 

Directory of Poison Control Centers 40 



Medical News Letter, Vol. 34, No. 5 



HISTORICAL FUND 

of the 

NAVY MEDICAL DEPARTMENT 

A committee has been formed with representation from the Medical 
Corps, Dental Corps, Medical Service Corps, Nurse Corps, and 
Hospital Corps for the purpose of creating a fund to be used for the 
collection and maintenance of items of historical interest to the Medical 
Department. Such items will include, but will not be limited to, por- 
traits, memorials, etc. , designed to perpetuate the memory of dis- 
tinguished members of the Navy Medical Department. These memorials 
will be displayed in the Bureau of Medicine and Surgery and at the 
National Naval Medical Center. Medical Department officers, active 
and inactive, are invited to make small contributions to the fund. It is 
emphasized that all donations must be on a strictly voluntary basis. 
Funds received will be deposited in a Washington, D. C. bank to the 
credit of the Navy Medical Department Historical Fund, and will be 
expended only as approved by the Committee or its successor and for 
the objective stated. 

It is anticipated that an historical committee will be organized at each 
of our medical activities. If you desire to contribute, please do so 
through your local historical committee or send your check direct, 
payable to Navy Medical Department Historical Fund, and mail to: 

Treasurer, N.M. D. Historical Fund 
Bureau of Medicine and Surgery (Code 14) 
Department of the Navy 
Washington 25, D. C. 



Committee 

F. P. GILMORE, Rear Admiral (MC) USN, Chairman 
C. W. SCHANTZ, Rear Admiral (DC) USN 
L. J. ELSASSER, Captain (MSC) USN 
R. A. HOUGHTON, Captain (NC) USN 
T. J. HICKEY, Secretary-Treasurer 



Medical News Letter, Vol. 34, No. 5 



Systemic Causes of Abdominal Pain 
Part I 

A brief history and physical examination often immediately estab- 
lishes the cause of abdominal pain. The physician identifies the disease 
entity in the same way that he recognizes the age of an octogenarian. It is 
not the scanty white hair alone — it is the entire picture that allows justifia- 
ble conclusions. Similarly, one has little difficulty diagnosing appendicitis 
when a text-book picture is presented. Not infrequently the cause of abdom- 
inal pain is not so classical. Many diseases cause abdominal pain in over- 
lapping and similar patterns and no wise physician fails for long to be 
impressed with his own fallibility. 

When the cause of a well-described abdominal pain is obscure, it is 
rewarding to approach the problem in an orderly manner. Such an approach 
is possible in two ways: to consider the neuroanatomy of the painful region, 
and to see how well the particular clinical facts can be explained by the 
characteristics of those diseases capable of producing abdominal pain. 

The first method is exemplified by differential diagnosis of chronic 
right upper quadrant pain. Attention is focused on the organs from which 
right upper quadrant pain may arise: liver and biliary tract, pancreas, 
hepatic flexure of the colon, adjacent muscles and portions of the pleura, 
kidney, stomach and duodenum, parts of the thoracic spine and cord, and 
possibly others. Review of features of the illness that suggest involvement 
of one of the structures named is made, and procedures or laboratory tests 
are completed to determine the validity of plausible anatomical possibilities. 

The second method does not confine itself to the immediate neural 
connections of the painful region. It begins with a categorical review of 
disease that can cause pain in the abdomen and clinical facts are questioned 
to determine whether they are compatible with various possibilities and whe- 
ther special procedures are necessary to establish the presence or absence 
of one or more of these diseases. This method is often a necessary supple- 
ment to the anatomical method for two reasons: viscera sometimes cause 
pain in unusual and unpredictable places, and detection of the precise anatom- 
ical location of the lesion that causes abdominal pain is not always possible. 

An example of the first anatomically confusing situation is the patient 
with peptic ulcer who complains of lower abdominal pain relieved by eating. 
One possible explanation is the summation of stimuli, postulating that sub- 
liminal impulses over the pain tracts from the bowel (due perhaps to a 
spastic colon) are added to similar impulses from the duodenum with resul- 
tant pain referred to the lower point. Whatever the reason for such atypical 
pain syndromes, the patient must always be the final arbiter of the location 
of the pain. The second type of anatomically confusing situation — the diseases 
whose pain-producing lesions are impossible or difficult to locate — present 
frustrating problems. These are the subject of the author's discussion. 



4 Medical News Letter, Vol. 34, No. 5 



Diseases Due to Hypersensitivity . Certain acquired diseases of con- 
nective tissues are usually loosely called "collagen diseases. " The relation- 
ship of these entities is controversial. Clinically they are confused with one 
another and with a great many other diseases. Their clinical manifestations 
may involve any part of the body, and among the symptoms they produce is 
puzzling abdominal pain. Sometimes the pain has a discernible cause, as in 
the sterile peritonitis of rheumatic fever or lupus, the gross infarctions of 
bowel or spleen in polyarteritis, the ulcerated bowel of lupus, the radio- 
logicfelly peculiar bowel infiltrations of scleroderma, and pancreatitis caused 
by lupus or polyarteritis. In addition, the so-called collagen diseases not 
infrequently give rise to mild or severe abdominal pain, of no consistent type 
or pattern, for which a specific anatomical cause is never found. 

Abdominal pain may be caused by a known allergin, as in a specific 
drug sensitivity or injection of horse serum, and abdominal pain may be a 
prominent feature of nonthrombocytopenic purpura whether an allergin has 
been incriminated or not. Abdominal pain may be produced when the sensi- 
tive individual is exposed to the allergin through any route, not necessarily 
by ingestion. In most instances, abdominal pain is neither the sole nor 
cardinal manifestation of the illness, but in any given case of allergic purpura 
or of serum sickness separate signs of those diseases may appear in all pos- 
sible combinations and permutations. 

Without detracting from the importance of allergy as a cause of abdom- 
inal pain, it must be confessed that recurrent or chronic abdominal pain is 
sometimes blamed on allergy when there is no evidence to support such a 
diagnosis. The patient may preier a phantom allergy to the scrutiny of real 
emotional turmoil, and the physician may encourage this deception for one or 
more reasons. 

Infections . In some instances, abdominal pain is the initial complaint 
in an illness as remote from the abdomen as streptococcal pharyngitis, influ- 
enza, or measles. Ordinarily, malaise and signs of systemic disease serve 
to minimize the deceptive localizing importance of abdominal pain. Certain 
specific infections — liver abscess of a staphylococcal septicemia, for exam- 
ple — may produce severe abdominal pain as a result of lesions in or near the 
abdomen. More often the lesion incites but does not require surgical treat- 
ment and the latter only aggravates the infectious process. Therefore, it is 
important to be wary of infections which are notorious for their imitation of 
a surgical abdomen, as "intestinal flu" and similar conditions. Less common 
infectious impersonators of a surgical abdomen are bacterial enteric pathogens, 
amebiasis, malaria, trichinosis, subacute bacterial endocarditis, rickettsial 
diseases, infectious mononucleosis, herpes zoster involving roots of an abdom- 
inal nerve, epidemic pleurodynia, gonorrhea in women, and mumps. 

Toxins. Abdominal pain is frequently caused by enterotoxins found in 
food, such as that produced by staphylococci. Clostridium botulinum produces 
a far more formidable toxin. Other foods contain intrinsic substances which 



Medical News Letter, Vol. 34, No, 5 



are toxins and often produce abdominal pain. Among these are the meat of 
some species of fish or mussels, mushrooms, grains contaminated with 
ergot fungus, milk from cattle that have been eating certain plants, raw 
sprouting potatoes which contain solanin, and various other normally edible 
materials. 

Drugs are not without potentiality for causing abdominal pain. The 
pharmacopeias of the world are saturated with chemicals and compounds 
whose toxic manifestations include nausea, anorexia, and abdominal pain. 
It should be remembered that native sensitivity of individuals to any single 
toxic effect of a drug is tremendously variable, not to mention the possibility 
of allergy. 

The list of chemicals capable of producing abdominal pain is lengthy. 
Any adult suffering from abdominal pain of obscure origin should be questioned 
carefully as to occupation, habits of cooking or eating, and chemicals used in 
the household chores, gardening, or hobbies. 

Abdominal pain following a bite by the black widow spider may be agon- 
izing. Often, the causative bite of arachnidism has not been recognized as it 
usually has been of little moment to the individual bitten. Acute symptoms 
last 12 to 24 hours and include muscular spasm severe enough to create a 
board-like abdominal wall. Careful attention to all possible etiological factors 
will prevent adding laparotomy to the misery inflicted by the spider. 

Metabolic Diseases and Electrolyte Disturbances . Abdominal pain may 
arise when the body's electrolyte balance is seriously disturbed. The faster 
the departure from normal ionic equilibrium, the more likely it is that smooth 
muscular contractions of the stomach and intestines will be augmented, de- 
pressed, or rendered dysrhythmic to the point of producing abdominal pain of 
various types and/or nausea and vomiting, diarrhea, or constipation. The 
situations that create these conditions are ordinarily simple, as in heat 
cramps produced by excessive sweating without adequate sodium replacement. 
Abdominal pain may be found, however, in complex electrolyte disorders, as 
in hepatic or renal diseases in which sodium, potassium, calcium, and chlor- 
ides may be diluted or concentrated — depending upon the circumstances — and 
in which acidosis, alkalosis, dehydration, or water intoxication may be pro- 
duced by erroneous treatment or therapeutic inactivity. Probably the com- 
monest electrolytic causes of marked abdominal pain or discomfort are 
hypokalemia and hypercalcemia. 

Uremia may be accompanied by a great variety of electrolyte disorders, 
the type depending upon underlying renal disease, speed with which renal fail- 
ure has developed, complications, and treatment. Nevertheless, it is clear 
that uremia includes much more than any known electrolyte disturbance. The 
mechanisms through which renal failure causes disordered motility of the 
stomach and intestines are very poorly understood and probably include as 
yet unidentified metabolic defects. 



Medical News Letter, Vol. 34, No. 5 



Hepatic insufficiency of any type, beyond its role in electrolyte dis- 
orders, sometimes promotes dysfunction of the stomach and bowel through 
mechanisms as yet not clarified. Pellagra causes diarrhea, and, along 
with other vitamin deficiencies is known to produce abdominal cramps and 
other gastrointestinal pains probably due to alterations in smooth muscle 
tone and motility. 

Diabetic acidosis is a condition in which causes of abdominal pain 
are interrelated with electrolytic and metabolic defects. Other endocrine 
disorders frequently presenting abdominal pain include Cushing's syndrome, 
Addison's disease, medullary tumors of the adrenal gland and hyper- or 
hypofunction of the thyroid and parathyroid glands. 

Several inborn errors of metabolism may cause severe abdominal pain 
simulating a surgical emergency— porphyria, hyperlipemia, and hemochroma- 
tosis. 

Periodic Peritonitis . Occasionally a benign self -limited form of acute 
peritonitis is seen, in a single attack or recurrently, for which no cause is 
found. In certain families such attacks of peritonitis — and sometimes pleu- 
ritis — are apparently inherited, The etiology is not known and the condition 
has been described variously as "periodic peritonitis, " "Armenian Disease, " 
and familial Mediterranean fever. (Mellinkoff, Sherman M., Systemic Causes 
of Abdominal Pain: Am. J. Digest. Dis., 4: 563-580, July 1959) (To be concluded) 

Tobacco Consumption and Mortality 

Employing the resources of the Veterans Administration in relation 
to the causes of death among 200, 000 policyholders of U. S. Government life 
insurance, the author applies statistical analytical methods and makes deter- 
minations of the relationship between a history of smoking and cause of death 
from cancer and other diseases. The data presented are based on 478, 952 
person-years of exposure of which 87, 774 were contributed by persons who 
had never smoked. 

The largest increase in mortality among persons who have smoked is 
found for those who have regularly smoked only cigarettes, being 58% higher 
than that for nonsmokers.- Regular cigarette users who had stopped smoking 
prior to the start of the study have a lower death rate than persons who con- 
tinued to smoke. Nevertheless, their death rate on the average still exceeds 
that for nonsmokers by 30%. 

The excess mortality of cigarette smokers is directly related to the 
average daily number of cigarettes smoked. Those who smoke two packs 
or more a day have the highest death rate — a rate averaging nearly twice 
that for nonsmokers. Only very heavy cigar or pipe smokers experience 
a higher mortality than nonsmokers. 



Medical News Letter, Vol. 34, No. 5 



By far the greatest increase for smokers in the risk of developing 
a disease is that for lung cancer. For all persons who had ever smoked, 
the observed number of cases of lung cancer was 312 compared with 52 
expected — a mortality ratio of 6.0. For no other disease does the excess 
mortality among smokers approach that for lung cancer, with the next high- 
est ratio being for a group of respiratory diseases including pulmonary 
tuberculosis, asthma, bronchitis, emphysema, pneumonia, and pleurisy. 

Nearly two-thirds of the deaths of persons who had used tobacco were 
attributed to diseases of the cardiovascular -renal system including chronic 
nephritis, arteriosclerosis, hypertension, rheumatic heart disease, chronic 
endocarditis, and coronary occlusion, sclerosis, and thrombosis. The risk 
of dying from one or more of these diseases is 31% greater for regular smok- 
ers than for nonsmokers. The death rate from coronary heart disease among 
regular users of cigarettes only is 63% higher than the rate for nonsmokers. 

Mortality ratios for cancer other than cancer of the lung are similar 
in magnitude to those for cardiovascular diseases. 

Smokers have no greater risk of committing suicide or of being killed 
in an accident than do nonsmokers. 

Diseases with a mortality ratio greater than 2. signifying a death 
rate more than double that for nonsmokers are bronchitis, emphysema, and 
allied respiratory diseases, cirrhosis of the liver, ulcer of the stomach or 
duodenum, cancer of the prostate, and cancer of the esophagus and buccal 
cavity. Several studies have reported that heavy smokers also tend to drink 
alcoholic liquors excessively so that the increased death rate from cirrhosis 
of the liver may reflect the effect of the consumption of alcohol rather than 
any effect of cigarette smoking. (Dorn> H. F. , Ph.D., Tobacco Consumption 
and Mortality from Cancer and Other Diseases: Pub. Health Rep. , 74: 581- 
593, July 1959) 

$ $ 4 jft * 4 

Clinical Characteristics of Leptospirosis 

Early discussions of leptospirosis primarily dealt with Weil's disease, 
a severe clinical syndrome characterized by fever, jaundice, renal damage, 
and hemorrhage. In recent years, attention has been drawn to the fact that 
leptospirosis is usually a mild disease in Which jaundice and significant renal 
damage are unusual, and that this mild form can result from infection with 
any of the leptospiral serotypes. 

Twelve sporadic cases of leptospirosis were studied by the author for 
analysis of the clinical characteristics. One feature was the biphasic nature 
of the illness. Initially, there was a 5 to 7-day period of fever, chills, head- 
ache, myalgia, conjunctivitis, and gastrointestinal symptoms. This was the 
"septicemic" stage as the organism was recovered from blood and cerebrospinal 



Medical News Letter Vol. 34, No. 5 



fluid in a high percentage of cases. The second stage began when deferves- 
cence and symptomatic improvement occurred, usually on the sixth or 
seventh day. Shortly following the end of the first stage there was a second- 
ary rise in temperature and development of meningitis, either asymptomatic 
or clinical. The blood and cerebrospinal fluid were sterile during this stage, 
but antibodies appeared in the blood in rapidly rising titer. The author con- 
siders that second-stage manifestations are primarily due to hypersensitivity 
and he proposes that this phase be designated the "immune" phase, with the 
previously suggested terms ''icteric" and "toxic" being inappropriate because 
of the low incidence of jaundice in leptospirosis in general, and because of the 
lack of evidence that toxins are important in the production of principal mani- 
festations. 

In the first stage, fever, chills, and headache occurred in all patients. 
The fever rose to lCk° F. or higher, and chills were recurrent in the majority 
of cases. The onset was abrupt in the typical occurrence. Headache — also 
seen in all cases — was usually frontal in location, intense, and unremitting. 
Myalgia, conjunctivitis, and anorexia were other frequently occurring mani- 
festations, Hematemesis and melena, reported by others, was not observed. 
A blotchy, erythematous eruption occurred in only two patients, and jaundice 
in one. 

Routine laboratory observations disclosed little significant change in 
the leukocyte count other than in the jaundiced patient who had a 35, 000 count 
on one occasion. Neutrophilia was a constant finding, along with an elevation 
of the sedimentation rate. Proteinuria and cylindruria were detected in two- 
thirds of the patients seen in the first stage, but the urine rapidly cleared 
after defervescence. The anicteric patients had only minor disturbances of 
liver function tests while the jaundiced patient had both clinical and laboratory 
evidence of severe hepatic damage. 

The second state in anicteric patients was remarkably benign. Several, 
including some who had overt meningitis, were clinically well by the 10th or 
11th day of illness. The jaundiced patient had slow recovery and was febrile 
until the 17th day and did not complete diuresis until the 23rd day.. The prog- 
nosis in anicteric leptospirosis is universally good and residual damage in 
any type of leptospirosis is rare. 

During the second stage, fever is common, but is low and of short 
duration. Since the blood and cerebrospinal fluid are sterile in the second 
stage, and symptoms develop at a time when antibody titers are rising and 
leptospires are being destroyed, development of an allergic state is possible. 

Meningitis is the principal second stage manifestation, and occurred 
in 10 of the 12 patients observed. It usually occurred 12 to 24 hours after the 
defervescence of the first stage, heralded by sudden recurrence of headache 
or intensification of a persisting headache. Nuchal rigidity in the first stage 
was considered not to be indicative of meningitis, but to be a result of diffuse 
myalgia, while in the second stage, nuchal rigidity was occasionally absent 



Medical News Letter, Vol. 34, No. 5 



even in the presence of symptomatic meningitis. Initial pleocytosis, up to 
533 cells /cmm., was of the neutrophil cell type in 4 and lymphocyte in 6 
patients, but lymphocytes predominated after the 12th day. The protein 
contents varied from normal to 140 mg. /100 ml. , and the sugar was normal 
or slightly elevated. 

The author is in agreement with the theory that an antigen-antibody 
reaction, rather than a manifestation of direct injury to the meninges by 
leptospires, explains the development of meningitis. He considers that this 
theory explains virtual absence of pleocytosis in the first stage, abrupt onset 
of meningitis around the 7th day, rapid disappearance of leptospires from 
the cerebrospinal fluid after onset of meningitis, good prognosis, and lack 
of correlation between severity of meningitis and manifestations of virulence. 
High incidence of meningitis is explained by the remarkable ability of lepto- 
spires to enter the cerebrospinal fluid during the septicemic phase. 

Diagnosis of leptospirosis depends on: (1) isolation of leptospires 
from blood; (2) fourfold or greater rise in complement -fixing or agglutination- 
lysis antibody titers, or both, during course of illness; (3) sustained titer of 
1:40 or greater by complement fixation or 1:400 or greater by agglutination- 
lysis when the first serum specimen was obtained on or after the 7th day of 
illness. The experience of the author did not support the view that different 
leptospiral serotypes cause distinctive clinical patterns of disease. Special 
diagnosis was impossible on the basis of clinical patterns of disease. 

Names, such as "mud fever, " "swamp fever, " and "swineherd's 
disease, " the author considers should be used only to draw attention to the 
epidemiological features of a given case, not to identity of the serotype, 
and use of the terms, "Weil's disease" and "pretibial fever" should be limited 
to the description of certain syndromes rather than as synonyms for infection 
with specific organisms. 

There is every reason to believe that leptospirosis is widespread in the 
United States, just as it is throughout the world. No doubt leptospirosis is 
present in many patients and is now being called "summer influenza, " "aseptic 
meningitis, " and "nonparalytic polio. " Among inhabitants of villages and rural 
areas leptospirosis is predominant in the summer and autumn, but among urban 
residents the seasonal incidence is less marked. As physicians become in- 
creasingly aware of the milder leptospiral infections, and with improvement in 
laboratory facilities for diagnosis, the number of cases being reported to 
public health agencies should be greatly increased. 

The greatest danger of infection in man is from contact with stagnant 
water to which wild or domesticated animals have access, but infection may 
result from direct contact with the urine of infected animals as well. 
{Edwards, G.A. , Clinical Characteristics of Leptospirosis: Am. J. Med., 
27: 4-16, July 1959) 

****** 



10 Medical News Letter, Vol. 34, No. 5 



Gushing 's Syndrome 

Recognizing that early diagnosis is of strategic importance in 
improving prognosis in individuals with Cushing's syndrome, the authors 
reviewed a series of 34 cases at the Lahey Clinic, placing emphasis on early 
symptoms and problems they may cause in differential diagnosis. 

The syndrome — a result of adrenocortical hype rfunction— has an es- 
timated duration from onset to death of slightly over 5 years, with death 
usually being brought on by infection, complications of cardiovascular dis- 
ease, or neoplastic disease. Treatment, reflecting recent advances in phys- 
iological understanding, yields more satisfactory results with early institution 
of specific measures as the ravages of the disease are in part proportional to 
the length of time the disease has been present. 

Insidious onset is commonly considered the picture of adrenal hyper- 
plasia, with rapid onset being characteristic of adrenocortical tumor. In the 
series studied by the authors, 24 (71%) presented initial manifestations that 
were dramatic enough to alert both the patient and the physician, with 5 of the 
group exhibiting remittent characteristics. Yet, of this group, 19 presented 
adrenocortical hyperplasia and 3 were diagnosed as adrenocortical tumor. 
Typifying these were 8 cases in which the disease began with edema of the legs 
and face accompanied by some other sign such as amenorrhea, renal colic, 
acne, hirsutism, bruises, weakness, mental symptoms, or diabetes mellitus. 

There were 10 cases (29%) with gradual onset, with clinical manifes- 
tations of mental changes, oligomenorrhea, gradual weight increase, hyper- 
tension, sterility, and diabetes mellitus — among others — so that no definite 
date could be ascribed to their initial appearance. 

Considering possible precipitating factors, emotional strain before 
onset of symptoms was described by several patients, and surgical or trau- 
matic stress was considered to be related to onset in others. 

Facial edema was a diagnostic pitfall in many cases, with hypothyroid- 
ism being diagnosed or suspected at some time in 7 patients, even though 
there were other signs inconsistent with this diagnosis. Hyperthyroidism 
was diagnosed in others because of increased nervousness among other symp- 
toms. A clue to be sought in the differential would be contradictory informa- 
tion of the basal metabolic rate and blood cholesterol. Individual determina- 
tions of cholesterol, basal metabolic rate, or radioiodine uptake may be 
normal, high, or low. 

Because of facial edema, the diagnosis of renal disease was made 
in some cases, while more widely distributed edema seemed to indicate 
cardiac or liver disease in others. A wide variety of skin changes, in 
addition to edema, led to further confusion. Thick skin and muscle weak- 
ness led to the diagnosis of dermatomyositis in one patient. The probable 
cai.se for the edema is a combination of factors including the tendency to 



Medical News Letter, Vol. 34, No. 5 11 



Hypernatremia, hypoproteinemia, and vascular fragility, all of which occur 
to varying degrees in Cushing's syndrome. 

Mental change was encountered frequently (88%) misleading the phys- 
ician making the original diagnosis to consider psychosomatic disease. Major 
mental changes were seen in 6 patients. Variations of the emotional and men- 
tal picture may constitute a real stumbling block in the diagnosis of this syn- 
drome. 

Diagnosis in the group with more insidious onset presented even more 
confusing diagnostic pictures. Among the more common findings were obesity, 
hypertension, hirsutism, diabetes mellitus, amenorrhea, and mental changes. 
Some helpful pointers in diagnosis are: combined appearance of high hemo- 
globin and leukocytosis with relative lymphopenia and eosinopenia; very high 
incidence of fatigue and weakness; nervous complaints; and striking change 
in appearance. Thoughtful analysis of the various factors presented, along 
with determination of the 17-hydroxycorticosteroid output, alone or after 
ACTH stimulation, should help to establish the diagnosis in the majority of 
such cases. In the list of differential problems, hypertension needs emphasis. 

Among the complications, osteoporosis — resulting from negative pro- 
tein and calcium balances — is commonly seen as an early sign which may 
lead to pathologic fractures. Renal calculi may result from the same imbal- 
ance. Hypertension may be a sign as well as a complication, persisting in 
remission. Other cardiovascular complications are well known. Infections 
have been the greatest single cause of death in the past and, despite anti- 
biotics, are still a problem. Duodenal uIccteb occurred in 3 of the 34 patients 
studied by the authors, with perforation occurring in one after years of inter- 
mittent ulcer symptoms. Three patients developed symptoms and signs of 
multiple peripheral neuritis, typical of Guillain-Barre syndrome, but without 
cranial nerve involvement. 

It is known that patients with Cushing's syndrome show enormous 
variations in excretion of steroids as determined by serial excretory estima- 
tions. It would seem correct, therefore, to state that type of onset, course, 
and manifestations of the disease at any given time will depend upon the 
amount and type of steroid secretion. A prolonged period of slight increase 
in steroid production by the adrenal :glands may cause symptomless changes 
until the stress of a complication, such as ulcer perforation or renal colic, 
triggers more obvious signs by resultant increased secretion. Therefore, 
remissions may be assessed accurately only after serial repeated laboratory 
studies, and without reliance on symptoms and more obvious signs. 

Cushing's syndrome is a rare disease. This fact alone makes it 
interesting, but its curability makes it a disease with which not only the 
endocrinologist but also every practitioner should be familiar. Unrecognized, 
irreversible changes may occur and fatality may be a result of complications. 
(Hurxthal, L. M. , O'Sullivan, J.B., Cushing's Syndrome - Clinical Differen- 
tial Diagnosis and Complications: Ann. Int. Med., 51: 1-15, July 1959) 



12 Medical News Letter, Vol. 34, No. 5 



Prophylaxis of Streptococcal Infections 

The relationship between group A streptococcal infections and the 
subsequent occurrence of rheumatic fever has been well established. It ■ 
has also been shown that initial and recurrent attacks of rheumatic fever 
can be prevented if streptococcal infections are prevented or effectively- 
treated. Sulfadiazine and penicillin, two of the most commonly used agents 
for prophylaxis, have been effective in reducing the incidence of recurrence 
of rheumatic fever but they both present the feature of producing undesirable 
reactions in 2 to 10% of the patients. In addition, the protection afforded 
by sulfadiazine is not complete. Because of these deficiencies other anti- 
microbial drugs might prove to be more ideal. The authors explored the 
possibility of employing erythromycin, an agent effective against group A 
streptococci and relatively nontoxic. 

Fifty patients with acute rheumatic fever or rheumatic heart disease 
were followed for an average of 19 1/2 months. While the number of patients 
was small, erythromycin probably was more effective than sulfadiazine, as 
only one patient receiving erythromycin acquired a group A streptococcus 
while seven of the group receiving sulfadiazine acquired the coccus. None 
of the patients receiving erythromycin for 9 to 24 months developed any 
type of reaction to the drug. 

One child in the study — in the sulfadiazine group — developed a recur- 
rence of rheumatic fever. When seen with an acute throat infection, ac- 
companied by a positive throat culture and antistreptolysin rise, this pa- 
tient already had a swollen joint. It is not known if recurrences in other 
patients were prevented by prompt treatment of their streptococcal in- 
fections with penicillin, but this seems a possibility since a high percent- 
age of rheumatic patients develop recurrence following untreated strepto- 
coccal infections. 

Streptococci other than the group A type were isolated from these 
patients while under treatment and observation. Rheumatic fever has not 
been associated with hemolytic streptococci other than group A, so the 
occurrence of these organisms in the patients receiving prophylaxis is of 
no significance as far as recurrences of rheumatic disease is concerned. 
On the other hand, since one group cannot be differentiated from the other 
by cultural characteristics, and because there is usually a delay of several 
days in the group classification of streptococci, it is necessary to in- 
stitute therapy without delay in order to be certain that all group A strepto- 
cocci are eradicated. 

It has been emphasized that patients who develop rheumatic fever 
following streptococcal infections show unusually high rises in antistrepto- 
lysin titers. It has also been shown that prompt eradication of strepto- 



Medical News Letter, Vol. 34, No. 5 13 



cocci from the throats of patients will result in a reduced or absent anti- 
streptolysin response. The development of significant antistreptolysin 
rises in only three of the eight patients from whom group A streptococci 
were isolated was probably due to the prompt and vigorous use of penicillin 
in these patients. (Stahlman, M. T. , Denny, F. W. , Jr. , The Prophylaxis 
of Streptococcal Infections in Patients with Rheumatic Fever: A. M. A. J. 
Dis. Child. , 98: 66-71, July 1959) 

# %t $t sjs sjs ^s 



Psoriatic Arthritis 



Many attempts have been made to define the entity, psoriatic ar- 
thritis. Some definitions have required a reasonable amount of synchronous 
activity — remissions and relapses in arthritis and cutaneous manifestations, 
arthritis restricted to distal interphalangeal joints, or a peculiar destructive 
form of arthritis associated with psoriasis. Hensch defined it as an atrophic 
arthritis following long continued and uncontrolled psoriasis. 

It is difficult to estimate the incidence of the association of the two 
diseases. Depending on which feature predominates, the patient may go to 
the dermatologist or rheumatologist and escape the statistical eye of the other. 

In recent years workers with the Rose -Waaler sheep cell agglutination 
test (SCAT), which is positive in 80% of patients with rheumatoid arthritis, 
have observed that most patients who had psoriasis and atrophic arthritis 
had a negative test. The present study analyzed 154 patients with psoriasis 
and various rheumatic complaints, comparing them with control groups of 
patients with uncomplicated rheumatoid arthritis and uncomplicated psoriasis 
respectively, in an attempt to resolve some currently conflicting views. 

As a result of his comparative analysis, the author considers con- 
firmation given to the belief that psoriatic arthritis is a distinct entity. The 
syndrome is characterized by a negative SCAT, whereas patients with co- 
incidental rheumatoid arthritis and psoriasis have a positive SCAT. The 
clinical course of the latter patients does not differ from those with un- 
complicated rheumatoid arthritis. 

Psoriatic arthritis may be virtually indistinguishable from rheuma- 
toid arthritis except that the age of onset is earlier, fewer joints are in- 
volved, and it is less disabling. It may, however, present primarily as 
distal joint arthritis closely associated with nail changes, or as a severely 
deforming type of arthritis. 

Some authorities have suggested that hemolytic streptococcus is the 
common etiological agent in psoriasis and its associated arthritis. This 



14 Medical News Letter, Vol. 34, No. 5 



relationship was not confirmed by the author's observations. The familial 
trend of the disease was evident in the study with previous evidence indi- 
cating a modified dominant genetic character. 

Only in deforming arthritis was psoriasis extensive. Contrary to 
some reports, the soles and palms were not involved more often in psoriatic 
arthritis, and pustular lesions which have been described as characteristic 
were only found significantly more often in deforming arthritis. Nail changes, 
commonly observed in psoriatic arthritis were seen in 81%, compared with 
32% of the control group with uncomplicated psoriasis. There was a closer 
association between nail and joint changes than skin and joint lesions. The 
fact that a high incidence of nail changes was found with coincidental rheuma- 
toid arthritis and psoriasis raises the possibility that such changes may not 
be specific for psoriatic arthritis but occur with any type of erosive ar- 
thritis. In patients with distal joint arthritis, however, the association ap- 
peared closer. The relation of involvement of the terminal phalanges to 
nail lesions may result from vascular changes, for it is known that similar 
changes may occur in vascular disorders,, such as Raynaud's disease. 

Although evidence suggests a close relation between psoriasis and 
arthritis in some patients, the joint and skin lesions required independent 
treatment. There was little to confirm the suggestion that the arthritis 
will subside with adequate treatment of the skin. Contrary to some reports, 
psoriasis was not usually resistant to treatment. Most patients were 
treated with full dithranol, tar bath, and ultraviolet -light regimen. 

Nail changes were resistant to treatment by local applications. Severe 
changes were treated with radiotherapy. The lesions resolved only to 
quickly recur. In no patients whose nails were treated by radiotherapy did 
the arthritis of the distal joints remit at the same time. 

Often the arthritis was sufficiently mild to require no treatment. When 
treatment was employed, conservative management was effective. Steroids 
were employed in a few with short-term improvement in the majority. 
Chrysotherapy was given to 48 patients with psoriatic arthritis, with no more 
frequent occurrence of toxicity than in 42 patients with rheumatoid arthritis 
treated with gold. {Wright, V., Psoriatic Arthritis: A. M. A. Arch. Dermat. , 
80: 27-35, July 1959) 

Change of Address 

Please forward requests for change of address for the News Letter to: 
Commanding Officer, U. S. Naval Medical School, National Naval Medical 
Center, Bethesda 14, Md. f giving full name, rank, corps, and old and new 
addresses. 

4 ■$ $ afc if; $ 



Medical News Letter, Vol. 34, No. 5 15 



Amenorrhea — Sign of Chronic Liver Disease 

Chronic liver disease as a cause of amenorrhea receives little 
recognition in standard textbooks of gynecology. The probable expla- 
nation is that in most cases of chronic liverdisease other manifestations 
such as jaundice or ascites are so prominent that amenorrhea is, by 
comparison, a trivial complaint. In some cases, however, amenorrhea 
is the presenting complaint and may bring the patient to the attention of 
the gynecologist who may not seriously consider chronic liver disease 
in differential diagnosis. 

In infectious hepatitis, a common occurrence during the disease 
is the development of complete amenorrhea which may persist for many 
months. Return to a normal menstrual cycle may be the sign of recovery 
of liver function. Modifications of the menstrual cycle have been reported 
by many as a concurrent part of the history of various types of chronic 
liver disease. 

In most reports, the presence of liver disease has been apparent 
on clinical examination of the patients, although in others the liver dis- 
ease remains obscure. One observer described the history of a 19-year 
old girl who presented with amenorrhea 3 years after an attack of in- 
fectious hepatitis, and who was found to have chronic hepatic cirrhosis. 
In this case, administration of estrogen produced severe jaundice. 

The authors reviewed 18 cases of amenorrhea associated with 
chronic liver disease, finding a mixed etiology for the liver abnormalities. 
Infectious hepatitis was the most frequent responsible factor with alco- 
holism and "lupoid hepatitis" being other factors. 

Why amenorrhea develops in these patients is not clear. An ap- 
parent relationship between estrogen and severity of the liver disorder 
has been suggested. Results of study have indicated that estrogens 
affect the turnover of phospholipids in the liver and the division and 
development of liver cells. Estrolipoprotein synthesis occurs in the 
liver and this reserve of free estrogen may be affected in chronic liver 
disease without alteration in the amount of estrogen produced, for the 
excretion of estrogens and gonadotropins is apparently low in this clinical 
state. Thus, no explanation can be offered that satisfactorily accounts 
for the amenorrhea in apparently related conditions. 

In all cases reported by the authors, flocculation screening tests 
for the presence of liver diseases were strongly positive, so that even 
in the few cases where liver disease was not obvious, if suspicion had 
been awakened, these tests would have strongly suggested the probable 
role of liver disease in production of the amenorrhea. (Green, P. , Rubin, 
L. , Amenorrhea as a Manifestation of Chronic Liver Disease: Am. J. 
Obst. &Gynec, 78: 141-145, July 1959) 

****** 



16 Medical News Letter, Vol. 34, No. 5 



Significance of Early Treatment of Breast Cancer 

Since 1948, the American Cancer Society, Inc. , and other educa- 
ational and public health agencies have worked to promote early detection 
and early treatment of cancer. With respect to the breast, for instance, 
both patients and physicians have been urged to seek out the small asympto- 
matic nodules and to have those that are suspicious removed. 

If this program of education has been effective, it will have resulted 
in tangible changes in the population of women being treated for breast cancer. 
Both the emphasis on placing breast cancer symptoms before the physician 
and the emphasis on the dangers of long periods of "observing" suspicious 
lesions will have acted to lessen reported intervals between the detection and 
treatment of breast cancer. The campaign for periodic examinations of sup- 
posedly normal breasts by patients and their physicians will have resulted 
in discovery of more cancers while they were small. This in turn will mean 
that even with a given amount of patient-physician delay, cancers treated by 
surgery would have been smaller in size. By both mechanisms the average 
patient prognosis would be better in the present decade than it was in the 
early part of the last decade. 

To study these points, the data on breast cancers seen at Memorial 
Center for Cancer and Allied Diseases, and Cornell University Medical 
College during 1950-1955 inclusive were compared with the data previously 
published on cancers seen in the years 1940-1943. The delays reported by 
the patients were tabulated and some improvement was noted in the later 
period. The size of cancers found at operation and the frequency and dis- 
tribution of node metastases during the two time periods also were compared. 
These figures showed a significant improvement. The patients of the 1950's 
had smaller cancers with fewer node metastases, and, when present, me- 
tastases were located lower in the axilla. All these findings are consistent 
with the hypothesis that education of the public and physician have been of 
some use. At the same time, the fact that many women still report long 
delays between awareness of the tumor and definitive treatment, and the fact 
that many large cancers of the breast are still being seen indicate how much 
work remains to be done. 

The same conclusion reached by the authors, that earlier cases of 
breast cancer are being seen in more recent years, can be drawn from other 
series. The operability rate has risen and the fraction of patients with 
operable cancer and without node metastases has risen. Perhaps the main 
contribution of the figures is to establish that to date more has been gained 
by promoting search for asymptomatic lesions than by the drive for less 
delay in treatment. Probably this could have been predicted. Delay, es- 
pecially by patients themselves is related to emotional factors as well as to 
knowledge. In addition perhaps it is easier to persuade physicians to look 
for more lesions to treat than to induce them to change their methods of 
handling the disease they find. 



Medical News Letter, Vol. 34, No. 5 17 



Finally, these figures should suggest caution to those who would see 
every change in cancer cure rates as triumph for a new technique of treat- 
ment. There are many ways in which prognosis for a group of patients can 
be changed by 5 or 10%. The only way to prove that the noted improvement 
has been caused by treatment is to make sure that cases are matched in all 
other ways. In breast cancer patients, age, tumor size, and degree of node 
involvement would seem to be the minimum characteristics to be matched. 
Because most series do not contain this information, much of their possible 
significance is lost. (Robbins, G. F. , et al. , The Significance of Early 
Treatment of Breast Cancer: Cancer, 1Z_: 688-692, July-August 1959) 

■.l* J* vU J> *b J* 

^1^ *^% wft ^p- <"f* *fl 

The Effect of Vaccine on Cancer Patients 

Cancer vaccines have been given in an effort to bolster the patient's 
resistance to cancer. This employment is based upon the hypothesis that 
some part of the tumor is antigenically different from the host and that host 
resistance is important in human cancer. 

Interest in the immune treatment of cancer was aroused by Jensen 
who observed that a transplantable mouse carcinoma could be caused to 
regress and disappear if treated with an immune rabbit serum. Other 
work, with variations and modifications, followed with the discovery of 
some encouraging features. 

Animals can be readily immunized against subsequent implants of 
transplantable tumors, but there are no experiments in which an established 
tumor is consistently and successfully treated by vaccine. This failure is 
due in part to the rapid course run by most transplantable and spontaneous 
tumors in animals. Two weaknesses have plagued human experiments and, 
to a large extent, the animal experiments as well: There has been no 
measurement except clinical course, which is notoriously difficult to 
evaluate; and, the vaccine ih each case has been either whole tumor, a 
fraction, or a product of the tumor, all of which are presumably found in 
the cancer patient and have been incapable of spontaneously eliciting the 
desired response. Therefore, a more antigenic preparation of the tumor 
must be used, or the patient must be changed so that he is more reactive. 
The present study pursued the former method introducing adjuvants with 
the tumor antigen. 

An adjuvant is an agent that aids the antigen to elicit a more vigorous 
immune response. If a destructive immunity can be elicited and directed 
against normal tissues, it seems reasonable to assume that a similar and 
more vigorous response could be produced against a cancer which already 
shows some evidence of antigenicity. 



18 Medical News Letter, Vol. 34, No. 5 



Experience with well-known infectious diseases has shown that the 
most effective immunization is conferred by the introduction of the living 
unattenuated organism: the attenuated organism is somewhat less effective, 
and the killed organism or its products is only active in certain instances. 
These observations have influenced the approach to tumor vaccines. 

A whole tumor preparation in a vaccine has the advantage of con- 
taining all ingredients, and it is hoped the body will develop the maximum 
immune response toward the elements that are most different from those 
of the host. For the current study, the authors employed various fractions 
of whole tumor preparation combined with Freund's adjuvant. 

During the course of treatment and observation, 101 patients with 
advanced cancer were followed for 7 to 30 months. Gynecologic cancer 
formed the bulk of the material. Of the 101 patients, 55% lived longer than 
7 months with many being observed as long as 3 years. Fourteen percent, 
apparently free of disease, were living at the time of the report, more than 
3 years after treatment. Nothing was observed to suggest that the vaccine 
contributed to the patient's death or progression of the disease. 

It was the impression of the authors that some of the patients had 
been benefited by the vaccine. It appeared to exert an effect potentiating 
radiotherapy. An unexpected feature of the study was the difficulty ex- 
perienced in obtaining sufficient tumor for preparation of the vaccine. In 
only a minority was the cancer found in large enough masses to provide 5 
gm. of relatively pure tumor. (Graham, J. B. , Graham, R, M. , The 
Effect of Vaccine on Cancer Patients: Surg. Gynec. & Obst. , 109 : 131-138, 
August 1959) 

****** 
Role of Salt and Renal Mass in Experimental Hypertension 

The induction of high blood pressure by increased salt consumption 
has been reported in the rat, rabbit, and chicken. Some animals have de- 
veloped severe renal disease associated with massive edema and a nephrotic 
syndrome. The experiments conducted by the author at the Institute of 
Pathology, Western Reserve University School of Medicine, were under- 
taken to (1) compare the effectiveness of salt and reduction in renal mass, 
individually and combined, in producing hypertensive vascular disease, and 
(2) clarify some aspects of the pathogenesis of both salt hypertension and 
renal -ablation hypertension. 

Chronic hypertension was readily produced in the rat by excessive 
intake of salt. The high blood pressure was associated with development 
of diffuse vascular disease, nephrosclerosis, and cardiac hypertrophy and 
thus resembled human essential hypertension. The condition was usually 
terminated by intercurrent infection, uremia, or a combination of the two. 



Medical News Letter, Vol, 34, No. 5 19 



Salt was capable of inducing hypertension without any reduction in 
renal mass. However, the hypertensive effect was substantially enhanced 
by such reduction. Unilateral nephrectomy alone gave hypertension in 
only an occasional instance, but when this procedure was combined with 
increased salt intake hypertension occurred in practically every animal. 
There was an interesting dissociation between renal disease and high 
blood pressure among rats receiving unilateral nephrectomy and allowed 
only tap water, i. e. , 56% developed nephrosclerosis of the remaining 
kidney and only 16% had hypertension. The reason for this is obscure and 
the result contrary to what was anticipated in view of the long-term nature 
of the study. 

The etiology and pathogenesis of human nephrosclerosis have not 
been established. It is commonly held that the renal disease rests primarily 
on a vascular basis — arteriolar sclerosis — but if so the cause of the sclerosis 
is unknown. On the supposition that vascular disease is primary, the glo- 
merular lesions have been attributed to ischemia, although thickening of the 
basement membrane of the capillary tufts constitutes a very early change. 
Evidence for infection as a causative factor is lacking. The role of hyper- 
tension in the induction of the vascular and glomerular changes still is not 
clearly defined. 

More is known about the pathogenesis of rat nephrosclerosis, es- 
pecially in connection with salt hypertension. From studies in the author's 
laboratory it appears likely that high blood pressure precedes significant 
morphologic damage to the kidney. However, hypertension per se is not 
considered to play the main role in initiating either the glomerular or the 
vascular change. The early stage of glomerular disease may precede or 
develop simultaneously with arteriolar lesions. Later, as the glomerular 
damage becomes diffuse, the vascular disease appears inadequate in 
distribution and severity to account for it. The evidence suggests that 
both the glomerular and the vascular lesions in rats with salt hypertension 
result from the injurious effect of the salt itself. 

Previous work revealed that a reduction in kidney substance is well 
tolerated initially, with eventual collapse under the strain of a continual 
functional overload. Most vulnerable to the excess work load are the glo- 
meruli. Evidently the excretion of end-products of protein metabolism 
and other substances is harmful. 

The author's present study provides convincing evidence that pro- 
longed high salt intake also has a deleterious effect on the kidney and 
promotes the development of nephrosclerosis. The renal damage from 
salt is readily obtained in intact animals and does not depend on reduction 
in renal mass. However, injury to the kidney -is'clearly augmented when 
fewer nephrons are available for function;'* 1 *^- 



20 Medical News Letter, Vol. 34, No. 5 



It is important to emphasize that focal lesions of early nephro- 
sclerotic type often occur spontaneously in the rat, the origin being ob- 
scure. An active role of salt in this process seems to be a distinct 
possibility. Other dietary constituents also might be implicated. 

In the author's opinion, no satisfactory evidence exists to prove 
that reduction of kidney mass, such as three-fourths ablation, results 
in the release of a pressor substance by the remaining kidney tissue, 
producing hypertension. His interpretation of completed studies suggest 
a different basis. Observing the progressive increase of frequency of 
hypertension with increasing loss of renal substance while on a high salt 
intake, it seems important that the greater the degree of renal ablation 
the more responsive the animal becomes to the hypertensive action of 
salt. According to this concept the hypertension following subtotal ne- 
phrectomy is mediated by the toxic effect of salt, presumably without 
elaboration of a renal pressor substance, although there is no evidence 
for the absolute exclusion of the latter. 

From the studies in the author's laboratory there appears to be 
a fairly well defined pattern of events in the induction of hypertensive 
vascular disease by salt. The primary injury is to the peripheral blood 
vessels and the initial effect is evidently functional and consists of in- 
creased vascular tonus. This gives rise to hypertension, which thus 
represents a very early sign, perhaps the earliest, of widespread peri- 
pheral vascular involvement. At the time hypertension is initiated, the 
blood vessels are either morphologically unaltered or show only sparse 
and relatively slight lesions. The high blood pressure is accompanied 
after a variable interval by progressive diffuse structural damage to 
arteries and arterioles in such sites as pancreas, mesentery, adrenals, 
gastrointestinal tract, and kidneys. The kidney lesions, especially those 
in the blood vessels, develop more or less simultaneously with those of 
the other peripheral vessels and are regarded as the renal component 
of the generalized vascular disease. Therefore the usual sequence in 
salt-induced hypertensive vascular disease is (1) increased tonus of 
peripheral vessels, {2) hypertension, (3) generalized vascular lesions, 
and, (4) nephrosclerosis. While the precise manner in which the vascu- 
lar injury arises is not clear, it may be related to electrolyte imbalances 
in the blood vessels initiated by retention of sodium and its subsequent • 
accumulation within the vascular wall. There is some evidence that 
hypertension itself is not responsible for the vascular lesions. 

While kidneys do not play the primary role in initiating salt hyper- 
tension, they have an ancillary one related to their capacity to deal with 
salt and perhaps water. Maintenance of electrolyte equilibrium within 
the body is an important aspect of renal function. 

The critical item in salt hypertension is of course its relation to 
human essential hypertension. That the latter is influenced by salt seems 



Medical News Letter, Vol. 34, No. 5 21 



certain from available data, and the possibility of a pathogenetic relation- 
ship cannot be excluded. From the pathologic standpoint there is much 
resemblance between the lesions of salt hypertension in the rat — diffuse 
vascular disease, nephrosclerosis, and cardiac involvement— and those 
of human essential hypertension. Over all, salt hypertension is much 
more like the human disease than is any other form of experimental hyper- 
tension. Thus there is a reasonable basis for the supposition that salt is 
an etiologic agent in essential hypertension in man. (Koletsky, S. , Role of 
Salt and Renal Mass in Experimental Hypertension: A. M. A. Arch. Path. , 
68: 11-22, July 1959) 



Association of Military Surgeons Annual Convention 

The 66th Annual Convention of the Association of Military Surgeons 
will be held at the Mayflower Hotel, Washington, D. C. , 9-11 November 
1959. Approximately 2, 000 American and international physicians, dentists, 
veterinarians, nurses, and medical specialist delegates will assemble for 
the series of meetings. 

Under the overall direction of the U. S. Air Force this year, the 
general chairman is COL Aubrey L. Jennings USAF MC, commander of 
the hospital at Andrews Air Force Base, with COL Frank M. Townsend 
USAF MC, the recently appointed director of the Armed Forces Institute 
of Pathology, as chairman of the scientific program committee. Major 
General Harold H. Twitchell USAF MC, President of the Association, has 
designated "Practice of Military Medicine — Broadening Concepts" as the 
theme for the meeting, and will present the opening address. The Navy 
Medical Department is represented by officers serving as members of 
various committees. 

The features of the Monday afternoon session, 9 November, include 
a lecture by Dr. Austin M. Smith, President of the Pharmaceutical Manu- 
facturers Association. Dr. Robert M. Chanock will speak on "Knowledge 
of Newer Respiratory Viruses, " Dr. William J. Brown will present a 
paper on "Present and Future Problems in VD Control, " and LT COL 
William H. Crosby MC USA, will discuss "The Danger of Folic Acid In 
Multivitamine Preparation. " 

The following morning the session will begin with the Porter Lecture 
on Trends in Mental Health by Dr. Paul H. Hoch, Commissioner of the 
Department of Mental Health for the State of New York, Dr. R. W. Postle- 
thwait will present "Gurrent Trends in the Indications for Surgery in 
Peptic Ulcer" and Dr. John M. Rumball will discuss "Changing Concepts 
of Nutrition Following Subtotal Gastrectomy. " 



22 Medical News Letter, Vol. 34, No. 5 



On Tuesday and Wednesday afternoons, a closed circuit color tele- 
vision program originating from Andrews Air Force Base, Washington, 
D. C. , will be shown, and will include presentations from the following: 
Air Force Clinic at the USAF Hospital, Andrews Air Force Base; USAF 
Epidemiological Laboratory; USAF School of Aviation Medicine; Armed 
Forces Institute of Pathology; Cape Canaveral; Air Force Missile Develop- 
ment Center; Bureau of Medicine and Surgery, Department of the Navy; 
Arctic Aeromedical Laboratory; and Aero Medical Laboratory, Wright 
Air Development Center. 

The program for Wednesday morning, 11 November, includes: "The 
Tissue Bank" by CAPT George W. Hyatt MC USN; "Medical and Surgical 
Aspects of Open Cardiac Surgery" by Brigadier General Clinton S. Lyter t 
MC USA; "Selective Malfunctioning of the Human Machine" by LT GQICOL 
Douglas Lindsey MC USA; 'Three Years Experience w&hvlmfcenfi-iye, Treat- 
ment and Recovery Unit in Medicine and Surgery": by GAPT Lewjis L.; Haynes 
MC USN; "The Use of Radioisotopes, rinsMedital P^aetice" by CAPT E. R-. 
King MC USN; "The Use of Fluorescent: Antibody Technics in Hospital 
Practice" by Dr. Ralph B. Hogan; VDrug Therapy in Hypertension" by Dr. 
Edward D. Fries; ; and "The .Useiand Abuse of Drugs" by Dr. Arthur Grollman. 

During the three-day meeting there iwill be; special section meetings 
with panel discussions for dentists, veterinarian^, nurses, and medical 
specialists. Films on medical and scientific subjects will be ; shown con- 
tinuously and approximately 60 technical and 12 scientific exhibits have 
been prepared. • 

Reserve officers attending the meeting will receive one retirement 
point for each day of attendance providing registration is made with the 
military representative present o n each day of attendance. 

Registration for the meeting will be made after 1300 on Sunday, 8 
November 1959. No registration fee is required. 

* $ # # # * 

Examination, Part I 
American Board of Obstetrics and Gynecology 

The next scheduled examination, (Part I), written, and review of 
case histories for all candidates will be held in various cities of the United 
States, Canada, and military centers outside the Continental United States, 
on Friday, 15 January I960. Candidates must submit rfta.se reports to the 
office of the Secretary within thirty (30) days of being- notified of their eligi- 
bility to Part I. Current Bulletins may be obtained by writing to: 

Robert L. Faulkner- r ,.M f D. d. 

Executive Secreta-ajy^nd Treas-u^erLre-, 

2105 Adelbert Road o 

Cleyeland6 K Ohio hi o 



Medical News Letter, Vol. 34, No. 5 23 



Applications for Training in Civilian Institutions 

In view of tlie need for early commitment with civilian institutions for 
training programs to begin in the Summer and Fall of I960, interested medical 
officers are urged to submit their requests to the Chief, Bureau of Medicine 
and Surgery prior to 30 September 1959. The types of Training Programs 
available are: 

1. Neurological Surgery — Completion of 1 year General Surgery 
required. 

2. Thoracic Surgery — Certification by American Board of Surgery 
required. 

3. Plastic Surgery — Completion of three or preferably four years of 
General Surgery required. 

4. Aviation Medicine (1 year for Master's Degree in Public Health) 

5. Occupational Medicine 

6. Public Health 

7. Radiobiology 

8. Subspecialties of Internal Medicine (Gastroenterology, Hematology, 
Allergy and Pulmonary Disease) — Completion, Part I, American 
Board of Internal Medicine, required. 

Individuals may indicate 3 choices of institutions in the order of 
preference as to where they desire the training. However, the Bureau of 
Medicine and Surgery will make the final arrangements for enrollment, after 
Bureau approval of the request has been obtained. Applicants may contact 
institutions relative to training but, in any correspondence or interviews, 
it should be made clear that any acceptance would be contingent upon approval 
being obtained from the Bureau of Medicine and Surgery. 

Applications from career medical officers qualified to enter these 
programs should be made by official letter to Chief, BuMed, via chain of 
command, and should include the obligated service agreement stipulated in 
BUMED INSTRUCTION 1520. 7B. Only a limited number of individuals will be 
sponsored in such programs in view of the existent personnel shortage. 

■^P 1 t ^F *r *f ^F 

From the Note Book 

Medical Annals . The July issue of the "Medical Annals of the District of 
Columbia, " a monthly publication of The Medical Society of The District 
of Columbia, was the National Naval Medical Center Number, with all 
professional articles being contributed by members of the staff of the Naval 
Hospital at the Center. Subjects discussed by members of various depart- 
ments of the hospital included: staphylococcal pneumonia, fibrinogen, cardiac 
arrest and resuscitation, deafness, external otitis, bicipital tenosynovitis, 
and torsion of the fallopian tube. 



24 Medical News Letter, Vol, 34, No 5 



USNH Great Lakes . The U. S. Naval Hospital, Great Lakes, Illinois has 
been approved for three full years of training in Internal Medicine. Previ- 
ously, only two years of training in that specialty had been approved for that 
hospital. 

A. P. A. Meeting. CAPT Leo J. Elsasser MSC USN, Director, Medical 
Service Corps Division, was the Surgeon General's representative to the 
House of Delegates of the American Pharmaceutical Association during 
their recent meeting in Cincinnati. LCDR Solomon C. Pflag MSC USN, Head, 
Pharmacy Section, Professional Division of the Bureau, acted as the Bureau's 
professional representative. During the course of the meetings, LCDR Pflag 
presided over the section on Military Pharmacy of which he is chairman. 

Military Entomology . A two week course in military entomology, dedicated 
to military entomologists who were killed during World War II, was presented 
by the Armed Forces Pest Control Board at the U. S. Naval Medical School, 
Bethesda, Md. , beginning 3 August 1959. The course, designed to acquaint 
entomologists within and outside the Armed Forces with the problems, 
techniques, goals, and philosophy of military entomology, was attended by 
10 civilians and 26 Armed Forces officers — 11 Navy, 10 Army, and 5 Air 
Force. 

NC Indoctrination Course. In response to the request of the Surgeon General 
that indoctrination of Nurse Corps officers be aligned with that of other 
women officers in the Navy, the Chief of Naval Personnel has established an 
8-week indoctrination course for Nurse Corps officers at the U. S. Naval 
School, Officer, (Women), within the Naval Schools Command, Newport, 
Rhode Island. 

The course of instruction is planned to aid the newly-commissioned 
Nurse Corps officer in adjusting to military life and acquainting her with 
her responsibilities and privileges as an officer. Appropriate theoretical 
background concerning the Navy Medical Department is provided, but no 
practical experience in a naval hospital will be given. 

On 1 July 1959 the first group — 53 Navy Nurse Corps Candidates — 
reported for the indoctrination course. 

Laennec's Cirrhosis. The authors studied 73 patients with Laennec's 
cirrhosis and observed that in patients with a normal range of blood ammonia, 
dietary regimen influenced neither clinical picture nor ammonia levels. In 
patients with high blood ammonia levels but without neurologic signs, a low 
protein diet appreciably decreased the ammonia level and increased the 
survival rate. Patients with neurologic manifestations and high blood am- 
monia levels also fared better. When glutamic acid was used as a sup- 
plement either orally or intravenously, ammonia levels dropped more 



Medical News Letter, Vol. 34, No. 5 25 



rapidly than when patients were on a low protein diet alone. High blood 
ammonia levels were clinically significant both as therapeutic guide and 
prognostic aid, whereas normal blood ammonia levels had no such signi- 
ficance. Arterial blood gives the most accurate levels as muscle tissue 
can remove up to 50% of ammonia passing through it, thereby lowering 
venous levels. (N. W. Chaikin and M. S. Loningsberg, Gastroenterology, 
June 1959) 

Pulmonary Disease and Ulcer. Noting the apparent increased frequency 
of gastroduodenal ulceration among patients with chronic pulmonary dis- 
ease in a hospital located in the heart of a coal mining area, the authors 
compiled results of their experiences. In the group there was an incidence 
of 25. 6% with a preponderance of the older age male. The atypical nature 
of the symptoms was stressed without apparent correlation of the in- 
cidence of ulcer disease with the severity of pulmonary disease. It was 
suggested that when anemia occurred with chronic pulmonary disease, a 
bleeding peptic ulcer should be expected. {W. O. West, et al, Arch. Int. 
Med. , June 1959) 

Breast Cancer . Adrenalectomy in advanced breast cancer was reviewed 
by Block et al at the University of Michigan, and included their own series 
of 27 patients. They showed that a random selection of patients will 
produce remissions in over 40%, being a reflection of chance association 
of patients who have hormonally sensitive tumors and whose internal 
endocrine environment is conducive to sustenance of these sensitive tumors. 
By careful selection of patients a remission rate almost double that of 
random selection can be achieved. Stressing that this form of treatment 
is one of palliation, with Addison's disease added to a possibly advancing 
lethal neoplasm, the following criteria were urged as a basis for em- 
ployment of adrenalectomy: (1) no involvement of liver; (2) previous re- 
mission from oophorectomy; (3) high estrogen excretion; (4) age between 
50 and 60 years; {5) prolongation of disease, usually over three years. 
(Surg. Gynec. & Obst. , June 1959) 

Tolbutamide . Although effecting good control in more than half of the pa- 
tients receiving it, tolbutamide exhibits the phenomenon of a subsequent 
loss of effect — secondary failure— which has been reported in 0. 3 to. 14% 
of all patients. Of the 200 patients of this report, 16% showed secondary 
failure, developing at unpredictable times. None exhibited significant toxic 
effects. Their data Confirmed previous reports that best results can be 
anticipated in the nonketotic, asymptomatic diabetic patient who is of near- 
normal weight, Over 40 years of age, and takes less than 40 units of insulin 
per day. (J. M. M6ss, et al, Ann. Int. Med., June 1959) 



26 Medical News Letter, Vol. 34, No. 5 



Magnesium and Labor. Incident to use of intravenous magnesium sulfate 
in treatment of toxemia of pregnancy, prolongation of labor has been ob- 
served. Assessing the role of the magnesium ion, the authors found that 
it inhibited contractility of isolated gravid human uterine muscle; and in 
clinical experience, did have a depressant action on uterine motility, al- 
though this effect did not detract from its use as the anticonvulsant of choice 

i toxemia of pregnancy. (D. G. Hall, et al, Am. J, Obst. & Gynec. , 
July 1959) 

Delirium Tremens, This study was designed to re-examine the rationale 
of treatment of delirium tremens — a combination of physiologic disturbance 
and emotional stress in an individual whose relation to reality is tenuous. 
The initiating mental event is "pharmacothymic crisis, " and the physio- 
logical disturbance consists of one or more of the following: dehydration; 
low serum magnesium; low salt syndrome; brain swelling. An inability to 
respond to stress is evident, and, owing to chronic vitamin deficiency, the 
alcoholic is found unable to respond with formation of mineralcorticoids. 
(H. Krystal, Am. J. Psychiat. , August 1959) 

Retrobulbar Neuritis in P. A . Presenting symptoms of pernicious anemia 
may be ocular with failing vision and blindspot. The pathologic process may 
be similar to subacute combined sclerosis occurring in the columns of the 
cord. Prognosis is good if adequate treatment is initiated early. (P. Ellis, 
et al, Am. J. Ophth. , July 1959) 

"ovine Bone Graft. Bovine bone marrow paste, and mandible and solid im- 
plants preserved in sterile bovine plasma was used in reconstructive 
surgery about the face. (N. Georgiade, Plast. & Reconstruct. Surg. , July 

'959) 

# * # * * * 

Policy 

The U. S. Navy Medical News Letter, is basically an official Medical 
Department publication inviting the attention of officers of the Medical 
Department of the Regular Navy and Naval Reserve to timely up-to-date 
items of official and professional interest relative to medicine, dentistry, 
and allied sciences. The amount of information used is only that necessary 
to inform adequately officers of the Medical Department of the existence 
and source of such information. The items used are neither intended to be, 
iior are they, susceptible to use by any officer as a substitute for any item 
or article in its original form. All readers of the News Letter are urged 
to obtain the original of those items of particular interest to the individual. 

-'.- «V *V •&/ it* «.l# 
+,+ rg. *£. *,v -f Sfi 



Medical News Letter, Vol. 34, No. 5 27 




DENTAL i.yj SECTION 



Corn Yields Tooth Clue 

A 10-year old discovery that Texas has something New England lacks 
has revealed a significant new approach to the prevention of tooth decay — the 
use of phosphorus. 

Dr. Robert S. Harris of the Massachusetts Institute of Technology, 
who made the discovery, found that hamsters fed on Texas corn and milk 
developed 40% less dental decay than those raised on the New England foods. 

After a long series of experiments with the animals, Dr. Harris 
concluded that the anti-decay factor was phosphorus — a simple abundant 
chemical. He has achieved 100% effectiveness in decay prevention among 
hamsters given four times the amount of phosphorus naturally present in the 
Texas foods. In addition, he told Science Service "the teeth grew in pearly 
white, and were lustrous and better shaped. " 

A Swedish dentist, Dr. Allen Stralfors of the Royal Dental Institute 
at Malmo, has obtained a 50% reduction in decay in the first human trial 
on 2, 000 children. The first United States trial is soon to begin among 
Indian children in South Dakota. 

Dr. Harris, 54-year old biochemist, is, presently working under a 
Naval Research Laboratory grant assisted by A. E. Nizel, D. D. S. After 
his initial discovery of the potency of the Texas -produced corn and milk, 
Dr. Harris took these steps: 

He burned the food, collected the ash, and added the ash to more 
food. Hamsters on this "reinforced" diet were almost entirely free of 
tooth decay. 

Dr. Harris then analyzed the ash, finding a number of chemicals, 
including phosphorus. He made a synthetic ash with the same chemicals 
and obtained the same results with hamsters. By leaving certain sub- 
stances out of the synthetic ash, he narrowed the anti-decay factor down 
to phosphorus. 

Trying various phosphorus -containing compounds in differing 
amounts, best results were attained with metaphosphoric acid in four times 
the amouttfeipresent in the Texas foods. (Science News Letter, 75, July 1$. i 
1959) 

****** .;= 



28 Medical News Letter, Vol. 34, No. 5 



Dental Care - Fiscal Year 1959 

During Fiscal Year 1959i 7, 285, 409 dental procedures were per- 
formed by an average of 1, 608 dental officers. Operative dentistry — fillings, 
crown, and bridge work — accounted for 2, 998, 258 procedures. In prostho- 
dontics, 13, 495 full dentures and 37, 385 partial dentures were completed. 
Extractions amounted to 350,250 teeth, and 1, 602, 325 dental x-rays were 
taken. Among other procedures were 235,453 prophylactic treatments, 
204,431 scaling (periodontal) operations, and 15,592 caries prevention treat- 
ments. 

****** 
Revised Prosthetic Handbook for Technicians 

A fully revised Technician Prosthetic Handbook is now available, 
The new handbook was prepared for use as a classroom text, as reference 
material for correspondence courses, and guide for nonsupervised labora- 
tory procedures. 

The handbook was prepared by the staff of the Naval Dental School 
under authority of the Dental Division, Bureau of Medicine and Surgery. 
A correspondence course using this handbook will soon be available. 

* 4 $ * * 




RESERVE SECTION 



Retention Beyond Age 60 Limited by Ruling 

Under present law, Reserve officers on inactive duty who are qualified 
for retirement with pay at age 60 may be retained in an active status beyond 
age 60 only under specific orders of the Secretary of the Navy. 

A recent decision by the Comptroller General has made it necessary 
to enforce this requirement in order to protect Reservists who are retained 
past this age. As a result of this decision, officers who are qualified for 
retirement with pay at age 60 are not eligible to earn additional credits toward 
retirement after they reach age 60 unless thay are retained in an active status 
under SecNav orders. The current policy with regard to retention and retire- 
ment is as follows: 

Inactive duty Reserve officers — other than flag and general officers — 
who are qualified for retirement with pay upon reaching age 60 shall be given 



Medical News Letter, Vol. 34, No. 5 29 



an opportunity to retire, as provided by law. However, if they fail to retire, 
they shall be discharged. For example, if an officer qualifies for retirement 
with pay on 15 June I960 and reaches age 60 on 12 August i960, he would be 
required to retire as of 1 September I960 or be discharged. 

All other officers shall be retired or discharged on the earliest of the 
following dates: 

1. Upon reaching age 60, the first of the month following the date on 
which they first complete their qualifications for retirement with pay. 
Thus, if an officer reaches age 60 on 15 June I960- and qualifies for retire- 
ment with pay on 12 August I960, he would be required to retire on 1 Sep- 
tember I960. Failure to retire would result in discharge. 

2. The first of the month following their 62nd birthday if retained, 
with. their consent, beyond age 60 under orders of the Secretary of the Navy. 
This category includes officers assigned to essential, hard-to-fill mobili- 
zation billets and who are, therefore, retained in an active status by SecNav. 

3. The first of the month following their 62nd birthday if they cannot 
qualify for retirement with pay on or before their 64th birthday, or if they 
were commissioned after 1 January 1953. 

Flag officers — with their consent — may be retained in an active duty 
status until age 62 upon orders of SecNav. The law also permits SecNav to 
retain, with their consent, a maximum of 10 flag and general officers in an 
active status until age 64. 

No officer may be retained in an active status after he reaches age 64. 

This policy will be incorporated in the BuPers Manual; details will be 
announced by BuPers Notice. {The Naval Reservist, June 1959) 

How to Accelerate AcDuTra Pay 

For those reporting for annual active duty for training, some suggestions 
follow for accelerating payment of AcDuTra pay and allowances. 

Basic Allowance for Quarters (BAQ) . Much time and trouble will be 
saved if substantiating documents for BAQ are completed and certified before 
reporting for AcDuTra. 

Dependency Certificate . Officers must file Dependency Certificate — 
Wife or Child under 21 Years, DD Form 137, or NavComp Form 2040, which- 
ever is available. Dependency Certificate — Mother and/or Father, NavCompt 
Form 2040-1, is required when appropriate. Enlisted Reservists must file 
Application for Dependents Allowance, NavPers Form 668. 

Failure to have these forms completed and ready for submission when 
requested will hinder or delay payment. When possible, forms should be ob- 
tained and completed at the Naval Reserve Training Center. 

Copies of Orders . Reservists sometimes lack the proper number of 
certified copies of orders, have incomplete orders, or fail to have necessary 



30 



Medical News Letter, Vol. 34, No. 5 



endorsements. All personnel are required to have the original and eight 
certified copies of orders complete with all endorsements, including signa- 
ture of the Reservist acknowledging receipt of orders, in their possession 
when reporting for AcDuTra. No copies of orders are to be detached unless 
more than the minimum number required are received. If fewer than the 
required number are submitted, the orders may be returned by the disburs- 
ing officer for preparation of additional copies. Particular attention must be 
paid to insure that all possible endorsements are completed before orders 
are submitted to the disbursing office. {The Naval Reservist, May 1959) 







OCCUPATIONAL MEDICINE 



Tetra-Ethyl Lead Poisoning 

Recently, three Navy men working aboard ship suffered severe acute 
tetra-ethyl lead poisoning. These men worked 6 or 7 hours in a closed space 
which contained a leaking gasoline pump. All three became comatose. Two 
of the men are making a satisfactory recovery, but the condition of the third 
is still critical. In view of the foregoing, the subject of tetra-ethyl lead poi- 
soning seems appropriate to review. 

Lead poisoning may occur in industry in two forms: (1) from exposure 
to the inorganic compounds of lead, and (2) from handling organic compounds, 
especially tetra-ethyl lead. The clinical picture is different in the two forms. 
Poisoning by the inorganic compounds causes colic, wrist drop, stippling 
of the red blood cells and anemia. In poisoning by tetra-ethyl lead the picture 
is that of insomnia, mental confusion, delirium, and mania. 

Tetra-ethyl lead is an organic lipoid soluble compound readily absorbed 
through the skin and respiratory tract. It is a clear, heavy, oily liquid with 
peculiar sweetish odor, is somewhat volatile at ordinary temperatures, and is 
added to gasoline as an antidetonant. 

In 1923, when tetra-ethyl lead was first manufactured in the United 
States, 149 cases of encephalopathy occurred in men employed at three separate 
plants. Within 17 months, 11 deaths were reported. Those affected suffered 
from restlessness, talkativeness, ataxia, insomnia, and delusions. There were 
no paralyses or convulsions, but the condition terminated with violent mania, 
shouting, leaping from bed and smashing of furniture. By attention to plant 
design, further catastrophies of this sort were avoided. Apprehension as to 
possibility of poisoning of garage and aircraft workers by lead from exhaust 
gases of gasoline has proved to be without foundation. 

During World War II, a new hazard arose in the process of cleaning 
storage tanks which had contained ethyl -gasoline. After the gasoline had been 



Medical News Letter, Vol. 34, No. 5 31 



pumped out and the air rendered gas -free by ventilation, floors, walls, and 
supporting pillars were scraped clean. Men engaged in the work were re- 
quired to wear an air-line mask and were supplied with a complete outfit of 
clothing including boots, gloves, and headgear. The protection afforded was 
satisfactory, but there were occasional instances of failure to obey the regu- 
lations with the result that 25 cases of poisoning by tetra-ethyl lead occurred, 
two of them fatal (Cas sells and Dodds, 1946). War conditions in the countries 
of the Middle East and Far East made cleaning the tanks difficult to supervise, 
and there were 200 cases of poisoning with 40 deaths. Unhappily, many of 
these cases were not recognized soon enough. 

Early symptoms include insomnia, loss of weight, anorexia, and morn- 
ing nausea. Mental manifestations dominate the clinical picture, and in severe 
cases restlessness, bad dreams, hallucinations, and delusions are common. 
Several symptom-complexes have been distinguished — delirious, manic con- 
fused, and schizophrenic (Macule, 1935). With severe exposure there may be 
abrupt onset of acute maniacal symptoms with suicidal tendencies or the occur- 
rence of convulsions. Less severe cases begin with insomnia— sleep being 
difficult, broken, and restless, sometimes with wild and terrifying dreams. 
By day, mental excitement may be marked, headache is usual and often severe, 
and vertigo is frequent. Blurred vision and diplopia owing to weakness of extrin- 
sic ocular muscles are occasional complaints. Evidences of meningeal irrita- 
tion are absent; the cerebrospinal fluid at times may be under increased pres- 
sure, but is not otherwise abnormal. 

Punctate basophilia is absent or slight and the test for its presence in 
blood, therefore, has little significance. Anorexia, nausea, and vomiting are 
constant; colic does not occur, but diarrhea sometimes develops. Many 
patients complain of a metallic taste in the mouth. Weakness, tremor, mus- 
cular pains and ease of fatigue are frequent complaints. The tremors affect 
the extremities, lips, and tongue, are coarse and jerky, and aggravated both 
by effort and by attempts at control. In patients who recover, all symptoms 
disappear in 6 to 10 weeks. Occasionally, an anxiety state persists for a 
time . 

In 1947, Bini and Bollea described two fatal cases of poisoning where 
ethyl -gasoline intended for use as aviation fuel was used for the dry cleaning 
of clothes. The patients were Italians, a man of 20 and a woman of 30, who 
cleaned and pressed the uniforms of American airmen stationed in Italy. They 
worked in a room which was small, closed, and poorly ventilated, and ironed 
clothes still wet with the leaded gasoline. After a few days' exposure they 
suffered from anorexia, vertigo, general weakness, and insomnia. About a 
week later there developed psychomotor agitation with a rapid stream of dis- 
connected speech and mental confusion. This state took the form of a toxic 
confusional delirium accompanied by visual and auditory hallucinations occur- 
ring together, tremors affecting all muscles, myoclonus, and choreiform 
movements. Two days later they became comatose and died with a tempera- 
ture of 105° F. At necropsy both cases showed the brain to have diffuse 



32 Medical News Letter, Vol. 34, No. 5 






hyperemia of the cortical grey matter and basal ganglia. Histologically, 
there were both diffuse and focal changes. Throughout the cerebral and 
cerebellar cortex there were diffuse acute degenerative changes in almost 
all nerve cells. In places, groups of nerve cells showed severe degenera- 
tive changes with complete' disintegration of cell bodies. Focal lesions were 
found, especially in the mamillary bodies and to a lesser degree in the floor 
of the fourth ventricle and in the corpora quadrigemina. Nerve cells in the 
mamillary bodies appeared to be severely injured and in some areas had com- 
pletely disappeared. In addition, there was intense proliferation of the glia 
with predominance of microglia cells. Where this occurred, there. was also 
new formation of capillaries and perivascular infiltrations with small round 
cells including mast cells. 

In mild cases removal from exposure, a normal diet with extra fluids 
and the relief Of insomnia by the proper choice of barbiturates are all that is 
required. Severe cases call for strict supervision and skilled nursing be- 
cause of hallucinations and impulsive suicidal tendencies. Morphine is con- 
traindicated; the sedative action of repeated doses of barbiturates together 
with adequate fluid intake being the essentials of treatment (Kehoe, 1953). 
Pentobarbitone sodium may be given in repeated full doses to obtain rest. 
Glucose, 5% in saline, may be given intravenously up to 3 liters a day, and 
if given as a drip, hexobarbitone may be added. Machle (1935) recommends 
the intravenous administration of from 2 to 4 gm. of magnesium sulphate in 
2% aqueous solution accompanied by dos-es of pentobarbitone sodium up to 
1 gm. daily by mouth. Cassells and Dodds (1946) found that enemas of 180 ml. 
of a saturated solution of magnesium sulphate often had a sedative effect when 
they could be retained. (The use of EDTA should be considered in severe cases.) 

Preventive measures include strict regulations for cleaning tanks which 
have contained leaded gasoline. Such work should be done under proper super- 
vision and by trained men properly equipped with protective clothing and breath- 
ing apparatus. Although ethyl -gasoline contains less than one part in a thous- 
and of tetra-ethyl lead, it should not be used for cleaning the skin. Leaded gas- 
oline mists must not be inhaled. The tragic events that follow inhalation of 
leaded gasoline mists were described in the incident of the Italian dry cleaners. 
(Excerpt from text: The Diseases of Occupations; Donald Hunter, M. D. , 
F.R. C.P.) 

EDTA Therapy in Excessive Lead Absorption 

Excessive lead absorption by persons in industry may occur as a result 
of one or more of the following circumstances: inadequacies or failures of 
existing measures for control of processes in which lead or lead compounds 
are used; poor personal hygiene; individual or group carelessness or indiffer- 
ence; unrecognized sources of exposure to lead; and, accidental exposure to 



Medical News Letter, Vol. 34, No. 5 33 



readily absorbed lead compounds such as tetra-ethyl lead. Since the prev- 
ious Lead Hygiene Conference, held in 1948, many fascinating contributions 
have been made in therapeutics. Notable among them were the introduction 
a-id use of EDTA (ethylene diamine tetra acetic acid) and its salts. 

Administration of EDTA or its mono- or disodium salts to the animal 
organisms results in the chelation and elimination of calcium. Because of 
this mechanism, it is not difficult to produce toxic manifestations with these 
agents. To avoid the possibility of producing a state of hypocalcemia, eda- 
thamil calcium -disodium is used. The administration of this compound in 
lieu of the acid or its mono- or disodium salts does not prevent the removal 
of lead from body fluids and, indirectly, the soft tissues, since it proceeds 
to replace the calcium in the ring because of the greater stability of the lead 
EDTA complex. The newly formed lead complex is highly soluble in water. 
Since the lead in the chelate is bound firmly and is no longer in an ionized 
state, it does not exert its characteristic toxic effects. It is apparent at this 
point that these properties of edathamil calcium -disodium meet some of the 
specifications for a suitable or ideal therapeutic agent of this type. The end 
product of such agents should have the following characteristics: it should 
be water soluble; it should be stable and not readily broken down by metabolic 
or other means within the body; it should be excreted rapidly; it should be 
readily absorbed and effective when administered orally; and, it should be 
relatively nontoxic when administered in effective amounts over prolonged 
periods of time. The latter includes the effects that might be induced by the 
depletion of trace metals that are necessary for the functioning of enzyme 
systems and other biologic mechanisms within the complex animal organism. 

It has been demonstrated that edathamil calcium-disodium is quickly 
and widely dispersed throughout soft tissues and body fluids after intravenous 
or intramuscular administration — not being concentrated significantly in any 
organ. The compound does not appear to enter cellular components of the 
blood, and the level in spinal fluid is far below that found in plasma. After 
parenteral administration of the drug, excretion occurs rapidly, primarily 
via the kidneys. It was found that over 50% was eliminated from the body 
within the first hour, while 90% was removed within 7 hours. The absorption 
of the drug from the alimentary tract is delayed and relatively poor. Evidence 
of renal damage has been observed in humans and degenerative changes in the 
tubules of the kidneys have been produced in animals when relatively large 
doses were administered over prolonged periods of time. 

The primary "deleading" action is apparently accomplished by remov- 
ing the lead from plasma and other body fluids. Shortly after intravenous 
administration of a dose, levels of lead in the blood may rise without producing 
adverse effects. The lead level then falls as excretion of the complex proceeds, 
Subsequently, the lead content of blood may increase appreciably, and it may 
attain very nearly its original high level as the lead in the skeleton tends to 
come into equilibrium with the body fluids and indirectly with the soft tissues 



34 Medical News Letter, Vol. 34, No. 5 



of the body. Following administration of the chelating agent, the rate of 
lead excretion is increased greatly, soon reaches a peak, then tapers off 
somewhat as administration of the chelating agent is continued. 

The recommended maximum dose for intravenous administration for 
each 10 lb. (4. 5 kg. ) of body weight is 0. 17 gm. per hour, 0, 33 gm. per day, 
or 1. 67 gm. per week. The drug in a concentration not to exceed 3% should 
be given in normal saline or in a 5% dextrose solution. The maximum dose 
per course of treatment is 2. 5 gm. for each 10 lb. of body weight. Courses 
should be separated by an interval of 7 days; it is inadvisable to exceed 2 
courses until or unless analytical results demonstrate a clear need for fur- 
ther therapy. Such need exists when the concentration of lead in the blood fails 
to diminish satisfactorily, or fails to remain well below a dangerous concentra- 
tion. All persons undergoing therapy should be checked frequently for evidence 
of renal damage. 

EDTA and the Prophylaxis of Lead Intoxication. The routine, frequent, 
or infrequent use of edathamil calcium-disodium or other present or future 
drugs as prophylaxis against the absorption of excessive quantities of lead 
cannot be condoned. Prophylaxis can be achieved safely only by controlling 
the sources of exposure to lead by the application of proper measures of 
industrial hygiene. The attitude that this cannot be accomplished generally 
in industrial operations reflects unawareness of the true facts or unwilling- 
ness to correct unsafe conditions (there are exceptions which result from the 
brevity of certain operations or the occurrence of unusual or unforeseen con- 
ditions). In the occasional circumstance where this is not practicable, strict 
adherence to recognized and properly supervised personal protective meas- 
ures, provision for adequate sanitary facilities, and insistence upon good 
personal hygiene and sound medical supervision of workers will prevent devel- 
opment of cases of lead intoxication. 

Quite apart from the fundamental philosophy that prophylaxis should 
be attained by control of environment, there are other valid reasons for not 
employing edathamil calcium-disodium as a preventive measure. 

1. The toxicologic potentials of the drug are not fully understood. 
The toxic effects observed in humans and animals from relatively short 
periods of administration have been mentioned; however, the effects that may 
be produced by administration to human beings of even low doses over pro- 
longed periods are not known and are matters for conjecture. 

2. Since this drug is absorbed poorly from the gastrointestinal tract, 
it is unlikely that the additional quantities of lead that may be eliminated by 
its use would be sufficient to prevent illness when compared with the total 
amounts of lead that are absorbed and retained during exposure to potentially 
hazardous conditions. 

3. Administration of the drug may mask the symptomatology of mild 
or early lead intoxication, thereby preventing recognition of hazardous expos- 
ure before a more serious or prolonged illness is produced. 



Medical News Letter, Vol. 34, No. 5 35 



4. While under the effects of the drug and for variable periods there- 
after, levels of lead concentration in the blood and urine are meaningless and 
may be misleading for diagnostic purposes. 

5. Use of such agents, regardless of their efficacy, tends to lull 
those persons responsible for the health of workers into a false sense of 
security which, invariably, is accompanied by relaxation of recognized pro- 
cedures and control measures. Such action leads to serious consequences for 
all concerned. 

Edathamil Calcium-Disodium and Lead Intoxication . Objectives of 
therapy in all cases of lead intoxication are to treat the acute episode and to 
assist the individual to return to his optimum level of health in the shortest 
time possible. Paramount to both objectives is the immediate termination of 
exposure to lead. With edathamil calcium-di sodium it is now possible to effect 
safely the elimination in shorter periods of time of appreciably greater quanti- 
ties of lead than heretofore. While this is highly desirable, the extent to which 
this modifies the ultimate clinical course of the disease cannot be stated with 
certainty. Dramatic subjective improvement shortly after institution of treat- 
ment has been reported in cases of poisoning from inorganic lead. In other 
cases, however, symptoms have persisted and have necessitated employment 
of additional time-proved measures, such as administration of calcium glu- 
conate intravenously for their relief. Other favorable responses, such as a 
sharp decrease in the numbers of "stippled" erythrocytes in the blood or con- 
centration of coproporphyrin in the urine, have been reported frequently. Some 
claims of subjective imporvement in mild cases probably have been over enthu- 
siastic because this occurs quite frequently soon after removal of the patient 
from exposure. 

In conclusion, edathamil calcium-disodium is a drug that is capable 
of forming a chemically inert lead-complex which is rapidly eliminated from 
the body. At present, it is believed that the drug is most useful in the treat- 
ment of the acute phase of the illness. However, it is likely that its principle 
virtue lies in its ability to expedite the elimination of potentially toxic quan- 
tities of lead from the body. By this means, one may hope to shorten the 
period of disability or of unemployment of the industrial workman. The body 
of knowledge concerning its useful application in cases of intoxication from 
lead and other metals is growing steadily, and it is hoped that its true value 
in therapy of lead poisoning soon will be established. (Miller, L. H. , EDTA 
Therapy in Persons with Excessive Lead Absorption from Industrial Exposure: 
Indust. Med., 28: 144-147, March 1959) 

****** 

Occupational Analysis of Coronary Disease Mortality 

The question of whether management is more susceptible to death due 
to coronary heart disease than nonmanagement was a primary reason for a 



36 Medical News Letter, Vol. 34, No. 5 



mortality study based on male employees of a large private industry. The 
study covered a 5-year period. Deaths were classified as they occurred 
according to the International List of Causes of Death. The results of this 
study indicate that top management has the lowest rate of mortality due to 
coronary causes of all groups considered, although the rate for all manage- 
ment appeared to be higher than for nonmanagement. 

A comparison of death rates from coronary causes and all causes 
showed a sharp rise in the proportion of coronary deaths from ages 26 to 40. 
At age 40 the ratio of coronary to total deaths leveled off, staying within the 
range of .30 to 40% through age 64. A slight decline appeared at the later ages. 

Active employees from ages 40 through 64 were used for making com- 
parisons between occupation groups. This group made up over 375,000 life 
years of exposure in the 5-year period from which 1, 082 deaths from coronary 
causes resulted. 

To make a comparison by occupation the employees were classified and 
divided into groups according to the type of work and responsibility involved. 
These groups were then combined into management and nonmanagement. The 
classification was somewhat arbitrary, but sufficiently accurate for the in- 
tended purpose. 

Even though management appears to have the higher level of mortality 
there seems to be no consistency within the groups. The subdivisions of the 
management group which includes officials, supervisors, and staff, and fore- 
men, could be considered roughly as top, middle, and lower management, 
respectively. The top management not only showed the lowest level of mor- 
tality for the management group, but for the entire group of employees. The 
mortality level of the middle management group goes up considerably from 
top management, but the level drops again for lower management. 

A high mortality in the clerical group was to some extent caused by a 
transfer of physically impaired craftsmen into this group. The extent that this 
would affect the mortality level of this group is not known; however, assuming 
that the effect would not be great, it would appear possible that a different dis- 
tribution of employees by occupation might change the results to show a higher 
mortality for nonmanagement than for management. 

The rates of mortality from coronary causes for active employees, 
service pensioners, and the combination of active employees and service 
pensioners were reviewed. The high rates noted for service pensioners shows 
that retirements prior to age 65 are heavily loaded with impaired lives. The 
fact that these lives were not included in the comparison by occupation could 
have some effect on the figures. The rates for the combined active and service 
pensioners indicate, however, that any difference caused by not including ser- 
vice pensioners would likely be very small and that the results would not be 
materially changed. The coronary mortality rate for combined active and 
retired male employees included in this study was substantially the same, but 
slightly lower than for the general male population of the United States, both 
being based upon the same distribution of lives. 



Medical News Letter, Vol. 34, No. 5 37 



Summarizing the results of this study, there was no material differ- 
ence in coronary mortality between the top management group and the crafts- 
men and laborers' group, but there was a marked difference between top 
management and middle management which is not explainable from presently 
available data. The popular notion that high executive positions are assoc- 
iated with high coronary mortality is likely due to the greater publicity 
connected with such deaths rather than to statistical facts. (Mortensen, J.M. , 
Stevenson, T. T. , Whitney, L. H. , Mortality Due to Coronary Disease Ana- 
lyzed by Broad Occupational Groups : A. M.Ai Arch. Indust. Health, 19: 
1-4, January 1959) 

$ $ sjt $ 4 a|e 

Occupational Health and the Local Health Officer 

To alert the health officer to opportunities presented by occupational 
health, some practicable yeardsticks should be developed to enable him to 
measure the strengths and weaknesses in his own situation. While these 
may serve as building blocks for local occupational health activity, they can 
rise only from the foundation of the health officer's personal interest. Four 
misconceptions account for the lack or stunting of this interest as reflected 
in the extremely slow growth of local occupational health activity over the 
past two decades. 

First, occupational health still carries a limited connotation for many 
people. The health officer should be reminded that occupational health encom- 
passes more than mine, mill, and factory. It embraces all places where 
people work including the farm. As the latter becomes more mechanized and 
as more and more toxic chemicals are employed, agricultural aspects of 
occupational health assume increasing significance. 

Second, occupational health activity at the local level should not be 
confined to identification and control of harmful exposures in the working 
environment. Rather, it is concerned with health maintenance of the em- 
ployed and it views various occupational groups- not as captive groups, but 
as potential action bodies needing help to solve general health problems. 

Third, industry is too often considered separate from community. 
In far too many areas both industry and the health department suffer through 
failure to communicate with each other. 

The fourth misconception is that an occupational health program must 
necessarily be a specialized and separate activity of the health department. 
In large communities this may be desirable, but in smaller communities of 
less than 100, 000 where the majority of local health departments are located, 
such activities may be carried out by the basic health department staff. 

Occupational Health Self-Appraisal . To explore the practicability 
and desirability of extending the health department's services to the employed 



38 



Medical News Letter, Vol. 34, No. 5 



population, the local health officer must be prepared to answer some fun- 
damental questions. 

What is the general health status of workers in the community? In- 
formation of this type may not be readily available for most health juris- 
dictions. If a specific determination cannot be made, experience from other 
areas may be helpful. For example, one health survey shows that: 

For every 100 workers about 1220 days of disability because of ill- 
ness are experienced annually or over 12 days per worker per year. 

For every 100 workers there are 526 illnesses annually and 121 of 
them are disabling. 

For every 100 workers there are about 62 accidents annually and 
28 of these occur at work. Of these 62 accidents, 13 are disabling. 

For every 100 "blue collar" workers there are about 68 accidents 
annually, about 40 of which occur at work. Although the average blue 
collar worker spends about one -fourth of his total time at work, almost 
two-thirds of his accidents occur at work. 

What are some of the specific occupational health problems in the 
area? Here, the types of hazards reported by departments with established 
programs can serve as a guide. The health officer should look for: derma- 
titis-producing substances; toxicity due to solvents and other chemicals 
used in the factory, farm, and even in the home; and, hazards due to carbon 
monoxide, lead fumes and dust, silica dust, and noise. 

What are the characteristics of the labor force? What is its size? 
How many women are there in it? What is the age and racial distribution? 
The employed group may be expected to amount to one -third or more of the 
population. Information of this type may be available from such sources as 
the publications of the U. S. Bureau of Census, the State Office of Employment 
Security or Economic Resources, and the local Chamber of Commerce. 
If the community is larger than 250, 000, larger industries will be 
found. Even in this larger plant group, however, the health officer cannot 
assume that all is well. .Less than 1% will be of a size that can afford to have 
their own medical departments and fewer still will have industrial hygiene 
services of their own or through their parent company. 

The local health officer can do much to encourage physicians in indus- 
try and in private practice, hospitals, and clinics to comply with any occupa- 
tional disease reporting laws in effect. Through the local medical society, 
reporting of diseases can be encouraged by offering assistance in the epidemio- 
logic investigation that may be required. Local programs frequently can be 
more effective than State programs in stimulating occupational disease reporting. 

Integration of Occupational Health. Once having recognized the impor- 
tance of extending health services to the employed population, the health officer 
must determine the resources that are available and assume the leadership role. 
There can be no substitute for personal effort — through visits to industries and 
attendance and participation in business, trade, and union meetings — to build 



Medical News Letter, Vol. 34, No. 5 39 



a good working relationship with management and labor. Close cooperation 
with the local medical groups is necessary in all health department opera- 
tions. In occupational health this relationship assumes new importance 
because of sensitive economic and legal factors. Effective occupational 
health orientation of the health department staff depends upon the health offi- 
cer's concept of how the program can best be integrated with other activities; 
his vision of the opportunity it offers for the furtherance of disease control, 
health education, nutrition, and other core programs through utilization of 
industrial grouping of adults; and the opportunities for training that he makes 
available to them. A growing number of local health departments are finding 
that with a minimum of training basic personnel can extend their services to 
places of employment. 

In extending the department's services to industry, the local health 
officer will encounter situations requiring specialized help. Where can it be 
obtained? In all but nine States, State occupational health programs generally 
found in the health department are available to assist in defining or control- 
ling an occupational health hazard, an industry- related community health 
problem, or in some cases, in assisting industry in establishing employee 
health programs. Supportive laboratory service is also available to him 
from the State agency. 

In carrying on a limited occupational health activity, the local health 
officer need riot be concerned with purchase of specialized equipment. Usually, 
State programs are equipped to lend such equipment as carbon monoxide indi- 
cators, radiation monitoring equipment, and temperature and humidity re- 
corders. These instruments can be used in a satisfactory manner by local 
personnel after some training. 

More detailed information will be found in a kit available to interested 
public health personnel without charge from the Occupational Health Program, 
Public Health Service, U. S. Department of Health, Education, and Welfare, 
Washington, D. C. This kit includes an occupational health self-appraisal 
form, a detailed guide for occupational health services in local health depart- 
ments, a comprehensive outline giving specific examples of how involvement 
of industry and its employees can strengthen the local health department prog- 
ram and vice versa, and several statements describing the role of various 
local health department personnel in occupational health. (Magnuson, H. J. , 
The Local Health Officer in Occupational Health: Am. J. Pub. Health, 49: 
610-615, May 1959} 

*f T* *r *p 3p *f- 

Use of funds for printing the Medical News Letter, has been approved 
by the Director of the Bureau of the Budget, 19 June 1958. 

****** 



40 



Medical News Letter, Vol. 34, No. 5 



Directory of Poison Control Centers 

• 

A Directory of Poison Control Centers was compiled from informa- 
tion furnished to the National Clearinghouse for Poison Control Centers by 
State Health Departments. It includes those facilities which provide to the 
medical profession, on a 24-hour daily basis, information concerning the 
prevention and treatment of accidents involving ingestion of poisonous and 
potentially poisonous substances. Notation is made of those units which 
supply informational services only. 

A limited number of this directory is available and may be procured 
without charge from the U. S. Department of Health, Education, and Welfare, 
Public Health Service, Accident Prevention Program, National Clearinghouse 
for Poison Control Centers, Washington 25, D. C. 

£ qft ♦ ♦• '♦ >S 



8C01 *°N |iuu«d 
SS3NISH9 "IVI3I JdO 



lN3H18Vd30 AAVN 
QlVd S33d aNV 30VlS0d 



aNVHjmvw Vi vasamafl 

&31N33 "IVOiaaW 1VAVN 1VNOI1VN 

ioohos "iv^iaaw ivavn - s *n 
AAVN 3 HI JO lN3WiaVd3Q